Play Contexts and Assessing Senses of Self in Children with Down Syndrome

by Tassillie Dent and Gregory Fouts

The purposes of this study were to (a) determine the feasibility of assessing three aspects of sense of self in young children (3 - 5 years) with Down syndrome, and (b) assess the effects of three social play conditions in eliciting the different senses of self. The three aspects of sense of self were body self, subjective self, and symbolic self; they were assumed to developmentally emerge in this order. They were assessed using three social play conditions: No Object play (vocal and physical games with no toys), Joint Object play (free-play interaction with objects promoting joint attention), and Toy Object play (free-play interaction with realistic and representational toys). The results indicated differential sensitivity of the play conditions to the senses of self. Body and subjective selves were most frequently exhibited in No Object play and least frequently in Toy Object play; symbolic self was most often exhibited in Toy Object play and least often in No Object play. Overall, the subjective self was the dominant sense of self exhibited by the children.

Sense of self is important because of its relationship to the development of healthy attachment relationships in infancy and early childhood and the learning of social, language, and play skills (e.g., Beeghly, Weiss-Perry, & Cicchetti, 1990; Sroufe, 1990; Stern, 1985). Most of the research examining sense of self in young children has used children's play to examine the symbolic thought processes underlying this construct. Few of these studies, however, have attempted a detailed assessment of sense of self in children exhibiting sensory motor level of functioning (Cicchetti & Beeghly, 1990). Past research (e.g., Cicchetti, Beeghly, Carlson, & Toth, 1990) suggests that children with Down syndrome have delays in their development of sense of self (e.g., in self-recognition, representation of self), although their general development appears to proceed in an orderly manner similar to non-disabled children. The purpose of the present study was to suggest a method of assessing sense of self in young children with Down syndrome (3-5 years), who are at a sensory-motor level of development (pre-symbolic) or in an early stage of symbolic concept development.

For most theorists and researchers, the concept of self involves the I/me or subjective/objective self-dichotomy. The infancy and early childhood literature incorporates the concept of self within the relational context with others (e.g., Damon & Hart, 1982; Harter, 1983; Krueger, 1989; Sander, 1975; Sroufe, 1990; Stern, 1985). The present study expands Krueger’s (1989) and Stern’s (1985) conceptualizations of self development. They suggest that sense of self has subjective and objective features which evolve out of physical and psychological structures through experiences in relationships with significant others. They have identified aspects of sense of self such as "body and psychological self" (Krueger, 1989) and "core sense of self, subjective sense of self, and verbal sense of self" (Stern, 1985). The present study takes a multi-disciplinary perspective on the development of the self, utilizing concepts from developmental and clinical psychology as well as physiotherapy and occupational therapy (Ayres, 1979; Burpee, 1985; Williams, 1983). From this perspective, we suggest that there are two kinds of pre-symbolic senses of self (body and subjective) in young children with Down syndrome as well as an emerging symbolic sense of self. We believe that an infant’s integration of the body sense of self lays the foundation for the development of an increasingly complex sense of self, which is subsequently manifested as a subjective sense of self and later as a symbolic sense of self. Thus, we assume that (a) the three senses of self develop in the hierarchical order of body, subjective and symbolic senses of self, and (b) the social play interactions between parent and infant shape the emerging senses of self (Dent-Cox, 1990; Stern, 1974, 1985). Presented next is a brief description of their development.

Body self. Body self has been defined as "the full range of kinesthetic experiences on the body's surface and in its interior, and the body's functions" (Krueger, 1989, p. 3). Children's knowledge of the body is organized on three levels that develop progressively. The first level, body schema, develops after birth as a non-symbolic, neural map of the body. It is a product of body movement and is dynamic in nature (Ayres, 1979). The second level, body awareness, begins to emerge around six months of age but does not fully mature until late adolescence (Ayres, 1979; Crider, 1981). It consists of internal and external knowledge of the body, e.g., labeling of body parts of the self and others. Body image emerges around 18-24 months (Burpee, 1985; Williams, 1983) and represents an integration of body schema, body awareness, and emotional and cognitive elements. This development of body self combines features similar to Stern’s (1985) concept of "emergent self" and "core self," Krueger’s (1989) concept of "body self," and William’s (1983) conceptualization of the development of body awareness in young children.

We argue that the body sense of self emerges from the physical interactions between an infant and its caregiver(s). For example, early social game interaction occurs between birth and seven months (Ross & Day, 1980). This involves the emergence of infant behavioral rhythms and the parents’ capacity to read, give meaning to, and interweave their vocal, physical, and affective rhythms with those of the infant. Social games are characterized by mutually shared rhythms that are in a perpetual state of negotiation from moment to moment (Stern, 1974). As the infant matures, mutually negotiated games give way to games with external rules such as peek-a-boo and rhymes and chants (Brunner & Sherwood, 1985). It is within this context of physical social play that an infant’s body schema and awareness develop (e.g., awareness of the body, its parts, and location in space, the body in relationship to another). At this stage of development, the focus of social play is the physical interaction between parent and infant. Therefore, in the present study, the body sense of self was assessed using physical play interactions in the absence of toy objects; this play situation was labeled as No Object Play.

Subjective self. Subjective self refers to the capacity to experience oneself as a distinct entity that is able to and is interested in, sharing a subjective focus with another (Stern, 1985). An infant's knowledge of the self is subjective, below the level of conscious awareness, and remains implicit in behavior (Bretherton & Beeghly, 1982; Bretherton, McNew, & Beeghly-Smith, 1981; Stern, 1985). Evidence for the subjective self includes sharing a focus of attention (Dunst, 1981; Landry & Chapieski, 1989; Stern, 1985), intentions (Bretherton & Beeghly, 1982), and affect states (e.g., affect attunement, empathy, social referencing; Stern, 1985).

Between 7-12 months, infants become more active participants at a simple sensory-motor level in social game playing with the caregiver (Ross & Kaye, 1980). Objects are often introduced into the playful exchange as a focus of joint attention (Landry & Chapieski, 1989). Turn-taking is often accompanied by affective and gestural signals between partners to indicate the intention for the other to join in the game or turn-taking (Ross & Kaye, 1980). Thus, infants develop the capacity to intentionally engage another in social interaction and show interest and willingness to share subjective experiences with others (Bretherton & Bates, 1979; Sroufe, 1990; Stern, 1985). From this pre-symbolic, sensory-motor object-oriented play, the subjective self is assumed to develop. Therefore, in the present study, the subjective self was assessed using interactive play which incorporates simple sensory-motor objects that support joint attention (but does not elicit symbolic themes); this play situation was labeled as Joint Object Play.

Symbolic self. Research in theory of mind and that of Stern (1974, 1985) suggests to us that a symbolic sense of self develops in the second year of life. Theory of mind is a term that refers to the ability of an individual to impute mental states to one's self and to others (Premack & Woodruff, 1978); this ability becomes increasingly observable between 12 and 24 months of age as toddlers develop language and symbolic play skills (Bretherton & Beeghly, 1982). This is due, in part, to the self being objectified, rendered explicit in language, and integrated as the young child matures (Beeghly, et al., 1990). By the end of the second year, symbolic role-play, internal-state language, and linguistic descriptive representations of self and others can be observed. These abilities enable children to reflect on their own and others’ mental states (Bates, 1990; Bretherton, 1984; Bretherton & Beeghly, 1982; Bretherton et al., 1981).

We believe that the symbolic self emerges from the mutual and increasingly symbolic interactions between an infant and its caregiver(s). For example, at 12 months, infants begin initiating game interactions with their parents; they serve as agents as well as recipients of the action (Ross & Kay, 1980). By 15-18 months, they invent new forms of old games and initiate novel game interactions; and by 18 months, their language and play behaviors with objects and partners becomes increasingly decontextualized, decentrated, and integrated (Beeghly et al., 1990), thus heralding the emergence of symbolic thought. This is facilitated by the use of toy objects (as in doll play, dramatic play with pots and dishes, and play with small replica toys) that support symbolic themes within the play interactions (Fein, 1981; Rubin & Howe, 1985). Therefore, in the present study, the symbolic self was assessed using interactive play which incorporates symbolic objects that elicit and support symbolic thematic play; this play situation was labeled as Toy Object Play.

In summary, the purpose of the present study was to determine the feasibility of assessing the three senses of self (body, subjective, and symbolic), two of which are pre-symbolic and one being symbolic, using three different social play situations. Each play condition was designed to optimize the assessment of a different sense of self by varying the presence or absence of play objects, demand characteristics of the play objects, and the quality of physical interaction between child and adult. Children with Down syndrome were used because past research (e.g., Beeghly et al., 1990; Cicchetti et al., 1990) has indicated that the development of such children, although delayed, proceeds in an orderly fashion similar to non-disabled children. Information gained from this study may be useful to advance research and habilitative work focused on the development of attachment relationships of children with one or more disability.

It was expected that the body self would be most evident in social play that allowed spontaneous and mutual negotiation of movement of body parts (No Object Play). This play would resemble that normally occurring between parents and young infants and would not depend on play objects that might distract or otherwise interrupt the focus on body movements and their interactive rhythms. The subjective self was expected to be most observable in social play designed to facilitate joint attention, communicative intention, and shared affect states through the use of play objects possessing low demand characteristics (e.g., balloons, bubbles) and eliciting high affect and sharing of subjective focus (Joint Object Play; Landry & Chapieski, 1989; Leland, 1983; Leland & Smith, 1982). And finally, it was expected that the symbolic self would be most evident in social play that uses play objects which elicit pretend themes (Toy Object Play; Fein, 1981; Rubin & Howe, 1985). This type of play object is similar to those typically used in assessing the symbolic representation of self (Beeghly, et al., 1990; Bretherton, 1986; Cicchetti, et al., 1990) and possessing relatively high demand characteristics (e.g., doll, doll bed, farm set). Such objects provide opportunities for symbolic role and object play, use of internal state language, and the coordination of mental states between players.

Four female children with Down syndrome (3.2 - 5.0 years) participated. Two were Caucasian, one North American Native, and one Filipino; each was reared at home, physically mobile and able to walk independently, and attended a child development day care center. Three of the four children attended a pre-school program designed for children with Down syndrome.

Each child participated in three dyadic social play conditions with the researcher (T. D.) each week for four consecutive weeks, with the order of play conditions randomized for each child each week. Thus, there were 12 play sessions per child. The style of interaction in each condition employed the qualities of social play normally occurring between parents and infants (Stern, 1974; 1977), e.g., mirroring, expanding/elaborating a child's emotional, physical, and vocal expressions. These spontaneous researcher behaviors were permitted in order to promote an empathic, flexible, and creative play environment. The researcher generally followed a child's lead but would direct the play activity if a child stayed at an activity too long.

Play Conditions

No Object Play

The researcher facilitated play by observing the child’s movements (e.g., knocking on a shelf), and then mirroring or elaborating these movements so as to create the potential for a turn-taking game. Movement play also incorporated elements from the Sherborne Developmental Movement Play Program (1990). This program facilitates the expression of body awareness, spatial awareness, and relationship play. No play objects were available which would direct attention away from one another; play included episodes of matching of vocal and body rhythms, hide-and-seek, peek-a-boo, and follow-me games.

Joint Object Play

Play was initiated and maintained by observing the child’s approach to play objects and providing verbal encouragement and behavioral support to the child’s initiative. This condition emphasized free-play interactions using materials that elicit sensory and/or motor involvement, possess low demand characteristics, and enable children to control, create, change, and develop the play activity (Leland, 1983; Leland & Smith, 1982). The materials (balloons, bubble blow, large pillows, rubber balls, baby powder, face crayons and scarves) were assumed to elicit a shared focus and enhance joint attention, intention, and affect within spontaneous and unstructured sensory-motor play.

Toy Object Play

Play was initiated and maintained by observing the child’s approach to a play object and providing verbal encouragement and behavioral support to the child’s initiative. This play emphasized free-play interaction with realistic and representational toys possessing high demand characteristics typically used in assessment settings to elicit symbolic themes (Fein, 1981; Rubin & Howe, 1985); the toys were colored blocks, a body part puzzle, a Fisher Price farm set, a plastic truck with people, a doll with hairbrush, baby bottle, dress-ups, a blanket, a stroller, a small kitchen center. These materials enable children to create, change or share symbolic themes and role play with the researcher.

Procedure

The research took place in a day care center. Initially, there was a lengthy period of familiarization (two to three hours per week for four weeks) with each child, familiarizing each child first to the researcher, then the room, and finally to the video camera and operator (unobtrusively located in a corner of the room). After the familiarization phase, the room was cleared of all materials except for (a) those used for each specific play condition, and (b) a photo album (located on the floor within full view of a child) which contained pictures of the child, researcher, and peers from the day care center. Also included in the album were pictures of other children and their family members exhibiting feelings of happiness, anger, sadness, fatigue, hunger, illness, surprise, and excitement. This album was used in each play condition to assess the linguistic representations of self and other, using the procedure developed by Bretherton and Beeghly (1982) and Beeghly et al. (1990). This assessment was initiated either by the child or the researcher.

Each play session consisted of a 5-7 minute warm-up (e.g., greeting, taking off shoes), the 25-minute play condition, and a 5-minute closure period (e.g., finishing spontaneous play, putting on shoes).

Coding and Reliability

A coding manual was developed to identify features of each sense of self. This manual contained definitions, examples, and criteria for assessing the three senses of self and their respective components that were derived from the research literature. Body self had five components: identification of body parts, body awareness of self, others and self-other (Bretherton et al., 1981), body spatial planes (Williams, 1983), and the body in relationship to objects and directions in space (Williams, 1983). Subjective self had three components: intentional communication (behavior regulation, joint attention, and social interaction; Wetherby, Cain, Yonclas, & Walker, 1988), role taken in sensory-motor play (passive role, active role, child as initiator, and child as inventor; Ross & Kay, 1980), and sharing of affective states (social referencing, affect attunement, and empathy; Stern, 1985). Symbolic self had three components: naming and personal pronouns which included references to self, other, and self-other (Bretherton & Beeghly, 1982); internal state language (perceptual, physiological, emotional, volition, cognition, and moral) which included references to self, other, and self-other (Bretherton & Beeghly, 1982; Cicchetti et al. 1990); and pretend role in social-dramatic and replica (toy) play (self as agent and representing self as other, self as active with person or toy as passive, replica play with child ascribing feelings/perceptions to toy, joint role play, and multiple self-other role play with child acting as narrator or coordinator of roles; e.g., Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979; Bretherton, 1986).

Three university students with backgrounds in linguistics and/or developmental drama were used as coders. They were extensively trained in the use of the coding manual with practice videotapes; they were unaware of the purposes and hypotheses of the study. Coder reliability for each of the components within each sense of self was initially assessed using practice tapes of the children videotaped during the familiarization phase in which the researcher and children played informally in the room in which the study would take place. Inter-coder agreement was determined by dividing the tapes into 1-minute intervals and determining whether the same specific component(s) of a sense of self (its presence or absence) occurred in each interval for both coders; differences in coding were noted and resolved and the coding criteria refined. Training continued until the coders and researcher exhibited consistently high levels of agreement for each component. After training, no further discussion of coding occurred.

There were 48 play sessions (4 children X 3 play conditions X 4 weeks). Each play session contained 25 1-minute intervals. The videotaped sessions were coded by the three student coders; each coded different categories depending on their background skill. The researcher randomly selected and coded 25% of the 48 play sessions coded by the student coders in order to determine inter-coder agreement, i.e., calculated using agreements divided by (agreements + disagreements) x 100. Inter-coder agreement for each component ranged between 83-99% except for intentional communication, which was 77%.

Results and Discussion

For each child, a global measure for each sense of self was determined by combining the respective components within each sense of self that were exhibited over the four sessions. This was done by (a) determining the percent of intervals in which each component occurred for each of the four sessions in a play condition, (b) calculating the mean percentage of intervals across the four sessions for each component, and (c) adding the mean percentages of intervals for each component within the respective sense of self and dividing by the number of components in the sense of self. This was done for each play condition. Two sets of results are presented: (a) the presence of the three senses of self for each child (collapsing across the three play conditions), and (b) the three senses of self exhibited in the three play conditions.

Sense of self.Table 1 presents the mean percent of intervals in which each global sense of self was exhibited for each child collapsing across the three play conditions. An examination of this table reveals a consistent pattern among all four children. The subjective self was clearly the most dominant, followed by the body and symbolic selves, respectively.

Table 1. Mean percent of 1-minute intervals for each sense of self, collapsing across the three play conditions.

Body Self Subjective Self Symbolic Self.

Child 1 19.6 46.0 8.6

Child 2 15.3 39.3 6.8

Child 3 19.5 50.8 15.5

Child 4 18.6 47.3 13.8

Overall mean 18.2 45.8 11.1

The predominance of the subjective self suggests that 3-5 year-old children with Down syndrome exhibit a sense of self typical of 9-18 month-old non-disabled children (Bretherton, et al., 1981; Bretherton & Beeghly, 1982; Stern, 1985). That is, they are able to share the "subjective matter of the mind" such as attention, intention, and affective states and are able to refer to self and others as distinct and similar. But, they have yet to fully emerge into symbolically representing the self and other, since the symbolic self was the least exhibited. This interpretation is consistent with past research indicating that children with developmental delays exhibit delays in the symbolic self (Beeghly, et al., 1990). The body self was exhibited at a frequency between that of the subjective and symbolic self. This suggests that the body self is no longer the primary focus of the self, but has sufficiently matured to act as a foundation for the subjective self. With the advent of intentionally directed communicative behaviors (subjective self) that accompany early object play interactions, the child’s sense of self is considered by researchers to be pre-symbolic and implicitly rendered in behavior (Bretherton & Beeghly, 1982).

The three senses of self in children with Down syndrome appear to be differentiated. If future research substantiates this pattern, there are three important implications. First, it is feasible to assess different senses of self in children who are in transition from a sensory-motor to symbolic level of functioning. Past research has almost exclusively focused upon representations of self and other at the symbolic level (e.g., Beeghly et al., 1990; Cicchetti et al., 1990), rather than attempting to assess different self-representations that may occur and be necessary for the emerging symbolic self. Second, it suggests that perhaps a pre-verbal, pre-symbolic self (combining the body and subjective selves) can be measured utilizing non-object and simple object play in children with developmental delays. This pre-symbolic self may be a more developmentally sensitive measure of intersubjective relatedness than the more cognitively based measures using traditional toys that facilitate the expression of symbolic themes. Further research is needed to document this speculation.

A third implication involves possible interventions. It is possible that through the identification of the current sense of self that a child is functioning at, interventions could be designed to strengthen their social and affective interactive skills which would facilitate the developmental catch-up necessary for their entry into a more mature level of thought and understanding of the self. This is consistent with and provides more credence to intervention strategies focusing on the maturation of the body and pre-symbolic psychological self for children who have special needs (Fieber, 1975; Jernberg, 1979; Jernberg & Booth, 1999; Sherborne, 1990). For example, all four children frequently exhibited intentional communicative behaviors, joint attention, and behavior regulation over social interaction across all three play conditions. This is typical of non-handicapped youngsters of the same mental age (Wetherby, et al., 1988), but contrasts with previous research indicating that children with Down syndrome make fewer requests for and assistance with objects than non-delayed children (Beeghly, et al., 1990). The present study suggests that dyadic interventions, using sensory-motor play focused on expanding and consolidating intentional communicative abilities at the level of subjective self, may lay the groundwork for later more normalized patterns of symbolic language ability.

Sense of self in the three play conditions. Table 2 presents the mean percent of intervals in which each sense of self occurred in each of the three play conditions, collapsing across children. An examination of this table reveals differential sensitivity of the play conditions for revealing the three selves in children with Down syndrome.

Table 2. Mean percent of 1-minute intervals for each sense of self in the three
play conditions (N=4)

Play Condition

No Object Joint Object Toy Object

Body Self 24.3 19.2 11.2

Subjective Self 54.7 47.5 35.4

Symbolic Self 7.1 4.9 21.5

The body self was exhibited most often in the No Object condition and least often in the Toy Object (symbolic) condition. This provides evidence that an assessment setting in which spontaneous and mutually negotiated movement of the body in relation to another, especially when there are no materials which may distract the players, appears to enhance observation of the body self. This may be particularly important in the assessment of sense of self in children with developmental delays related to physical or sensory impairments and/or whose expression of self-other is pre-symbolic.

The subjective self for all children was most frequently exhibited in the No Object play condition and least frequently in the Toy Object play condition. This consistent pattern suggests that the optimum setting for assessing the subjective self in children with Down syndrome involves social play in which high sensory-motor and/or relational play interaction occurs. The use of body movement or objects with low-demand characteristics appears to facilitate a subjective and shared focus (Stern, 1985). The finding that the subjective self occurred least often in symbolic play (Toy Object) may be of particular interest to those working with children exhibiting developmental delays. This suggests that toys having high demand characteristics may distract such children from spontaneously negotiating aspects of shared focus such as joint attention (Dunst, 1981; Landry & Chapieski, 1989; Stern, 1985), intentional communication (Bretherton & Beeghly, 1982), and the sharing of affective states (affect attunement, social referencing, and empathy; Stern, 1985).

As expected, symbolic self, though least dominant overall, was exhibited most frequently in Toy Object play for all four children, with relatively little occurrence in the No Object and Joint Object play conditions. This supports past research indicating that toy materials possessing relatively high demand characteristics elicit pretend themes (Fein, 1981; Rubin & Howe, 1985) and demonstrate abilities such as symbolic linguistic and nonlinguistic representations of the self.

Conclusion

One implication of these findings is that different assessment settings may be useful in eliciting and supporting different senses of self in children, especially those in transition from sensory-motor to symbolic development. The present research suggests that traditional play assessments of children with developmental delays typical of non-disabled 9-18 month-old children, which utilize symbolic toy objects, may not capture the abilities and senses of self that serve as precursors for the symbolic self. Awareness of the importance of the play contexts in which the senses of self are optimized will likely facilitate decisions regarding treatment interventions. For example, if difficulties in parent and/or peer interactions are presented, therapeutic interventions using conventional (high demand characteristic) toys to facilitate the subjective self and relational play may be of limited success. The present study suggests using play materials that promote mutuality and a coordination of focus of attention optimize the development of the subjective self and joint play in children whose fine-motor object manipulation abilities and cognitive development are still immature. Similarly, if the goal of treatment is to improve the body self, using developmental movement play (Sherborne, 1990) with no objects present, may be a more successful approach. Research aimed at extending this line of research and verifying these implications for intervention is needed.

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Submitted by

Tassillie Dent M.Sc.
Chartered Psychologist (Alberta)
Registered Clinical Cousellor (B.C.)
3046 West 7th Ave. Vancouver, B.C.
Canada V6K 1Z8
E-mail: Tassillie@yahoo.ca

Gregory Fouts, Ph.D.
Professor
Department of Psychology
University of Calgary
Calgary, AB
Canada T2N 1N4
E-mail: gfouts@ucalgary.ca